Chapter 10 Shoulder Injuries

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Chapter 10Shoulder Injuries
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Chapter Objectives

• Understand the basic anatomy of the shoulder.
• Explain how shoulder injuries occur.
• Describe the various types of injuries to the
  shoulder.
• Explain treatment procedures fro common shoulder
  injuries.

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Anatomy

• Bones
• Humerus
• Clavicle
• Scapula

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Humerus
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Scapula
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Clavicle
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Anatomy

• Ligaments
• Coracoclavicular Ligaments
• Trapezoid
• Conoid
• Acromioclavicular ligament
• Corocoacromial

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Muscles

• Rotator Cuff
• Subscapularis
• internal rotator
• Infraspinatus
• external rotator
• Teres Minor
• external rotator
• Supraspinatus
• primarily an abductor of the arm

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Muscles

• Deltoid
• Attaches to acromion process and lateral humerus
• 3 portions
• Anterior, posterior, and medial
• Abducts, flexes, and extends the shoulder

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Muscles

• Pectoralis minor
• Pectoralis major
• Primarily responsible for horizontal adduction
  and protraction

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Muscles

• Biceps brachii
• 2 heads
• Originates at supraglenoid tubercle and corocoid
  process
• Inserts at radius
• Bicep tendon/bicipital groove
• Held in place by transverse ligament
• Flexes elbow, abducts and supinates forearm

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Muscles

• Triceps brachii
• 3 heads-long, lateral, and medial
• Originate posterior humerus
• Insert at ulna
• Extend elbow, humeral adduction

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Joints

• Acromioclavicular (AC) joint
• One of most common injured areas of shoulder
• Consists of acromion process and distal clavicle
• Held together by the ac ligament

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Injured AC joint
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Joints

• Glenohumeral joint
• Articulation of the humerus and glenoid fossa
• Very susceptible to injury due to fossa being
  shallow
• Humeral head covered with articular cartilage
• Capsular ligament surrounds the entire joint
  which aids in joint stability

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Injuries- prevention

• Shoulder injury causes
• Muscle weakness
• Postural problems
• Nature of the joint

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Addressing muscular weakness

• Often weak in posterior (back) muscles
• Signs- rounded shoulders, tight pectoralis
  muscles, weak posterior shoulder muscles
• All predispose athlete to injury
• Proper technique in throwing, swimming, etc.
  prevent injury
• Proper padding important

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Common shoulder injuries

• Acromioclavicular ligament sprain
• Aka-separated shoulder
• most common mechanism of injury occurs when the
  athlete falls onto the point of the shoulder or
  receives a direct blow to the tip of the shoulder
  or falls on an outstretched arm
• graded according to the degrees  of severity

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AC sprain (cont.)

• Mild (1st degree)
• stretching or slight tearing of the ligament
  fibers
• Mild joint tenderness, mild swelling, and little
  or no disability of the shoulder
• Moderate (2nd degree)
• partial disruption of the supporting ligaments
• pain and tenderness directly over and around the
  joint, local swelling, and an increase in pain on
  forced motion
• Severe (3rd degree)
• total disruption of one or more of the supporting
  ligaments
• varying degrees of tenderness, swelling,
  instability, and an increase in pain with any
  effort to stress the joint
• often exhibit a piano key sign that is, the
  clavicle can be pushed down but will spring back
  up when pressure is released. 

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AC sprain treatments

• PRICE
• Refer if 2nd or 3rd degree to r/o fracture
• 3rd degree may require surgery or harness
  immobilization

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Glenohumeral ligament sprain

• sprains of the shoulder joint seldom occur unless
  there is a subluxation or dislocation
• Vulnerable in abduction and external rotation
• Pain with any motion
• PRICE and refer to physician

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Rotator cuff strain

• Injuries to rotator cuff muscles are difficult to
  detect and isolate because these muscles, which
  reinforce the joint capsule, lie deep in the
  shoulder
• MOI-
• ballistic arm activities
• forceful concentric contraction of the muscles
  that accelerate and decelerate limb activities
• improper warm ups
• muscle fatigue

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Rotator cuff injuries (cont)

• Signs and symptoms
• anterior-lateral shoulder pain
• point tenderness
• decreased range of motion
• loss of strength consistent with the severity of
  the injury
• Pain may radiate down the lateral arm but usually
  stops at mid-humerus
• Pain is often increased at night while the
  individual is lying on the affected side

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Rotator cuff injuries (cont)

• Treatment
• PRICE
• Gentle strengthening and flexibility exercises
• See handout for examples

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Impingement sydrome

• common injury involving the soft tissues of the
  shoulder comprising of the subacromial space
  (often involves the supraspinatus and biceps)
• Usually result of repetitive overhead types of
  movement
• Treatment
• Modified activity
• Strengthening posterior shoulder muscles
• Improving flexibility (especially in pecs)

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Bicipital tendinitis

• Common with overhead activities (swimming,
  throwing, etc)
• Tendon becomes irritated in bicipital groove
• May feel crepitis (grinding)
• Rest and immobilization may be required
• Treat with Ultrasound and N-SAIDS

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Bicep tendon rupture

• Caused by direct blow or severe contracture
  forces
• Athlete will have inability to flex the elbow
• Noticeable deformity as bicep muscle will roll up
  under skin
• Treat- ice, immobilized, refer to physician
• Surgical repair necessary

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Clavicular fracture

• Most often fractures occur in distal 1/3 of bone
• Usually caused by direct blow or falling on the
  tip of the shoulder
• Restrict motion with sling and ice
• Refer for x-ray
• Most fractures take 6 weeks to heal

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Humeral fracture

• Not difficult to find if fractured at midshaft
• Shoulder can sometimes hide humeral head
  fractures
• Pain on all sides of bone when palpated (around
  circumference) is good indicator of fracture
• Splint and refer for immediate care
• Check pulse before and after splinting to check
  circulation

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Epiphysis injury

• Can be caused by
• Blow to humeral head
• Falling on elbow and driving humerus into glenoid
  fossa
• Signs/symptoms-same as humeral fx
• Treat with ice, splint, sling
• Refer, can cause growth impairment
• Young pitchers prone to epiphyseal injury from
  excessive throwing

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Avulsion fracture

• Can accompany a glenohumeral or AC sprain
• Capsular ligament pulls away from scapula when
  humerous dislocates from glenoid fossa
• Only revealed or ruled out by x-ray
• Treat with splint and ice

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Glenohumeral dislocations and subluxations

• Head of humerous is out of the socket
• Sublux- head was out, then back in
• Cause-excessive abduction and external rotation

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Glenohumeral dislocations and subluxations

• Dislocation can cause tear of the capsular
  ligament
• Anterior dislocation most common
• Deformity usually seen at deltoid muscle
  (shoulder flat)
• X-ray needed to determine extent of injury

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Glenohumeral dislocations and subluxations

• Dislocations and subluxations need to strengthen
  adductors and internal rotators
• Can wear restrictive harness
• Surgery sometimes required to repair capsular
  ligament

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Adhesive capsulitis

• frozen shoulder
• inflammation about the rotator cuff and capsular
  area that can result in dense adhesions and
  capsular contractures causing restriction of
  motion and pain
• exact cause remains unknown
• The main feature is a lack of passive range of
  motion

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Brachial plexus injury

• normally involves the cervical spine, but the
  symptoms are exhibited in the shoulder and upper
  extremity
• Usually caused by forced rotation or lateral
  flexion
• Is a stretching or pinching of brachial plexus

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Brachial plexus injury

• result in transitory paralysis of the arm
• numbness or a burning sensations radiating down
  the arm and sometimes into the hand
• Weakness or numbness lasting more than an hour
  should be referred to a physician

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Thoracic Outlet Syndrome

• a group of symptoms resulting from compression of
  the thoracic neurovascular bundle
• .  This neurovascular bundle emerges from the
  thorax though an outlet or triangle formed by the
  scalene muscles and the first rib
• Narrowing of the outlet can cause a variety of
  symptoms

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Thoracic Outlet Syndrome

• Possible causes
• hypertrophy of one of the scalene muscles
• shape of the first rib
• scar tissue formation around the nerve roots
• cervical ribs
• excess callus formation as a result of a
  fractured clavicle
• hyperabduction or stretching of the brachial
  plexus

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Thoracic Outlet Syndrome

• Symptoms
• aching pain across the shoulder
• pain in the side of the neck and down the arm
• sensation of weakness, heaviness, and easily
  fatigability when using the arm
• Athletes exhibiting TOS often have a history of
  trauma to the head, neck, or shoulder area

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